Tranexamic acid (TXA) in Trauma

TXA in trauma has been a hot topic for several years in the medical community…. So why bring it up again? Across Europe, this drug is being used widely in both the prehospital and hospital environments. When it comes to emergency medicine in the USA, we aren’t hitting as high on the bar as our friends across the pond.

Mechanism of Action for TXA

TXA is a synthetic derivative of Lysine which is an amino acid. Why is this important? It binds to and inhibits the clot buster plasminogen. You may wonder why plasminogen sounds familiar? It’s because we give it in stroke patients as tissue plasminogen activator (tPA). When TXA binds to plasminogen (because it’s a competitive inhibitor), it prevents plasminogen from converting to plasmin which breaks down already formed clots. In simplistic terms, TXA protects already formed clots in the body. For people who want to learn about the coagulation cascade, here’s a nice video on it. It’s important to remember that TXA has been shown to reduce the risk of hemorrhagic death by 1/3.

https://www.youtube.com/watch?v=JoPQEDt1b0w

When to Use TXA

TXA is supposed to be given within three hours of the traumatic incident. Here is a list of contraindications:

  1. Isolated head injury
  2. History of renal injury/failure
  3. Patient has a history of a thromboembolism
  4. Hypersensitivity to TXA
  5. Do not give in conjunction with prothrombin complex concentrate (PCC)

But with contraindications, there are indications:

  1. After a massive transfusion
  2. Hemodynamically unstable patients
  3. Systolic BP is less than 90
  4. Patient is at risk for life threatening hemorrhage after trauma

Here is some adverse reactions to TXA:

  1. Anaphylaxis/skin rash
  2. N/V
  3. Embolism
  4. Dizziness
  5. Hypotension secondary to rapid infusion (>100mg/min)

The adult dose for TXA is 1 gram over 10 minutes followed by 1 gram over 8 hours (mixed in with normal saline or D5W). Note: If you need a reason to give D5W over saline, check out our normal saline lethal triad post.

TXA use in the USA

With the CDC confirming over 140,000 deaths due to traumatic injuries, why wouldn’t the USA be more inclined to use TXA especially since EMS usually is the first healthcare workers on scene and can easily administer it within the 3 hour window especially if there is entrapment. The CRASH-2 study showed amazing promise by looking at TXA use throughout the world and saw a 20% lower mortality rate. Surgeons across the USA were asked to answer a survey and there are the results: “A recent questionnaire asked USA trauma surgeons if they use TXA in practice; “TXA was available at 89.1 per cent of centers. Experience with TXA was variable: 38.0 percent use regularly, 24.9 percent use it 1 to 2 times per year, 12.3 percent use it rarely, and 24.7 per cent had never used it. Among surgeons who had used TXA, 77.1 percent noted that TXA had reduced bleeding, but 22.9 percent indicated that it had not. Reasons for not routinely using TXA included uncertain clinical benefit (47.7%) and unfamiliarity (31.5%). Finally, 90.5 percent of respondents indicated that they’re looking toward national organizations to developing practice guidelines.” (Jawa, Singer, Mccormack, Huang, Rutigliano, Vosswinkel).

Key points

TXA should be administered in patients who have a high susceptibility to death secondary to hemorrhage. It’s of extreme importance that we don’t forget about the more normal resuscitative measures in our critical trauma patients. TXA is an interesting drug for our hemorrhagic patients and there have been many studies to support its use in emergency medicine. For now, the Europeans and other countries across the way have easier access to this medication; America will just have to wait for it to expand for now.

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This site is meant to be used for educational use only. We strive to push evidence based medicine with no bias to help you obtain all the important information. You should always follow your protocols that have been set in place.

Scopeducation Team (Matt)

References

DS. Kauvar, R. Lefering, et al. “Tranexamic Acid and Trauma-Induced Coagulopathy.” Journal of Intensive Care, BioMed Central, 1 Jan. 1970, jintensivecare.biomedcentral.com/articles/10.1186/s40560-016-0201-0#:~:text=It%20recommends%20the%20administration%20of,3%20h%20following%20an%20injury.

Jawa RS, Singer A, Mccormack JE, Huang EC, Rutigliano DN, Vosswinkel JA. Tranexamic Acid Use in United States Trauma Centers: A National Survey. Am Surg. 2016;82(5):439-447.

CRASH-2 Study PDF

https://pdfs.semanticscholar.org/3d42/7c96ea06c21e1b605c299d39e3d56e1d2692.pdf?_ga=2.269088050.277725616.1597264375-674099691.1597264375

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